Helmets: Limited Defense Against Concussions

Action Points

Protective sports equipment in use today does not lower the incidence of concussions among players, so the emphasis must remain on rapid assessment and appropriate removal from play, according to an international consensus statement.

Note that if evaluation of an athlete indicates the presence of concussion, the player should not be allowed to return to play that day, and should not be left alone as symptoms may worsen over the ensuing hours.

Protective sports equipment in use today does not lower the incidence of concussions among players, so the emphasis must remain on rapid assessment and appropriate removal from play, according to an updated consensus statement.

"There is no good clinical evidence that currently available protective equipment will prevent concussion," stated Paul McCrory, MD, of the Florey Institute of Neuroscience and Mental Health in Heidelberg, Australia, and colleagues.

Accordingly, when a sports participant demonstrates any potential symptoms or signs of concussion -- loss of consciousness, headache, irritability, or slowing of reaction time -- a physician or other healthcare professional should promptly perform an evaluation that includes assessment of cognitive function, McCrory and colleagues stated online in the British Journal of Sports Medicine.

If this evaluation indicates the presence of concussion, the player should not be allowed to return to play that day, and should not be left alone as symptoms may worsen over the ensuing hours, according to the consensus statement.

This statement represents the fourth iteration of recommendations for concussions in sports, intended to reflect changes in the understanding of the injury and its outcomes.

It is based on the conclusions of an international meeting held in Zurich in November 2012 and has been supported by various athletic organizations such as the International Football Association Board, the International Rugby Board, and the International Olympic Committee.

"The current supplement is the result of more than 10 years of continuous scientific collaboration of the involved partners, which has raised awareness in the international sports federations, stimulated research output, and outlined the possible ways where research should be guided in the future to be able to present scientifically proven and sound guidelines for return to play after sustained concussion," Mark Aubry, MD, of the International Ice Hockey Federation in Zurich, and colleagues wrote in an accompanying editorial.

The authors of the statement emphasized that scientific understanding of head trauma is a work in progress, and that clinical management and decisions about return to play must be based on skilled judgment and individual circumstances.

The statement defined concussion as an injury to the brain resulting from biomechanical forces that usually leads to brief symptomatic impairments in neurologic function and generally is not associated with structural changes on standard imaging studies.

While symptoms resolve in 7 to 10 days in most patients, some patients experience prolonged recovery times and may require more detailed diagnostic investigations such as neuropsychological testing, which can determine if cognitive recovery has occurred and therefore can help in determining a suitable time for return to play.

Postural stability testing also can be useful in determining motor control status, particularly in patients whose symptoms included problems with balance.

Extensive imaging tests are not currently considered routine except when there is suspicion of structural damage, but modalities such as MRI increasingly are being explored for a role in diagnosis and monitoring as well as to further elucidate the underlying pathophysiologic events.

The consensus statement also summarized current thinking on treatment of concussion.

"The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and [return to play]," the authors explained.

However, actual evidence for the effects of rest is lacking, so they advised that a "sensible approach" would be to allow a gradual return to nonsport activities at a pace that does not lead to symptom recurrence or worsening.

They recommended this graded protocol, which usually takes a week, for decisions on return to play:

Treatment also may include a psychological component, particularly for depression and anxiety, but any pharmacologic treatments used should not be able to mask concussion symptoms.

Certain factors such as gender and length of time spent unconscious may modify the effects and outcome of concussion, the authors noted.

While females may be at greater risk for injury and may experience worse injuries, there was insufficient evidence to determine if this should be considered an important modifying factor.

But time spent unconscious, if more than 1 minute, was determined to be a factor that might influence treatment, the authors agreed.

Age also must be considered, as children may experience concussion differently and may take longer to recover.

"Because of the different physiological response and longer recovery after concussion and specific risks (e.g., diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative [return to play] approach is recommended," McCrory and colleagues observed.

They noted that, while the use of helmets and other protective equipment has not decreased rates of concussion, it can minimize some of the impact force of hits on the brain.

But protective equipment also can have negative consequences, with "behavioral change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates," they pointed out.

Unnecessary violence therefore should be discouraged, and emphasis placed on good sportsmanship and respect.

The authors concluded that their document, which should only be considered a general guide, will continue to be updated as concussion knowledge and experience further evolve.

The lead author has consulted and received reimbursement from organizations involved in sports injury including the International Olympic Committee, and has received consulting fees from Axon Sports and CogState.
Co-authors have been supported by various organizations including the International Football Association, Major League Soccer, the National Institutes of Health, CDC, the New Jersey Commission on Brain Injury, and have acted as advisors to the National College Athletic Association, Major League Soccer, and the National Hockey League.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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